Adult hip conditions and surgery

Question 1

can you make more hyaline cartilage

Answer 1

no

Question 2

what is femoroacetabular impingement syndrome (FAI)

Answer 2

when altered morphology of the femoral neck and/or acetabular causes impingement of the femoral neck on the edge of the acetabulum during movement

Question 3

what movement usually cause FAI

Answer 3

flexion, adduction and internal rotation (pulling on your shoe)

Question 4

what is a CAM type impingement in FAI

Answer 4

femoral deformity- asymmetric femoral head with decreased head:neck ratio

Question 5

who gets a CAM type FAI

Answer 5

usually young, athletic males

can be related to previous SUFE

Question 6

what is a pincer type inpingement in FAI

Answer 6

acetabular deformity- acetabular overhang (extra bit of bone or acetabular tilted forward)

Question 7

what does FAI cause in the joint

Answer 7

damage to the labrum and tears
damage to the cartilage
osteoarthritis in later life

Question 8

what is the usual presentation of FAI

Answer 8

activity related pain in the groin- particularly flexion and rotation
difficulty sitting
C sign positive
FADIR provocation test positive

Question 9

what is C sign positive

Answer 9

when patients with FAI are asked to describe their pain they will make a c shape with their hand and place it around hip joint

Question 10

what is the FADIR provocation test

Answer 10

flexion, adduction, internal rotation- if maneuver produces pain suggestive of hip impingement

Question 11

what can you diagnose FAI

Answer 11

radiographs, CT, MRI (better for visualising damage to labrum and bony oedema)

Question 12

what is the management for FAI

Answer 12

observation in asymptomatic patients

arthroscopic or open surgery to remove CAM/ debride labral tears

periacetabular osteotomy/ debride labral tears in pincer impingement

arthroplasty older patients with secondary OA

Question 13

what is avascular necrosis

Answer 13

failure of the blood supply to the femoral head resulting in subsequent necrosis

Question 14

what causes AVN

Answer 14

idiopathic:

• coagulation of the intraosseous microcirculation
• venous thrombosis causes retrograde arterial occulsion
• intraosseous hypertension
• decreased blood flow to the femoral head
• necrosis of the femoral head
• chondral fracture and collapse

AVN associated with trauma
-injury of femoral head blood supply (medial femoral circumflex)

Question 15

who gets avascular necrosis and in which hip?

Answer 15

males more than females
typical age 35-50
80% of cases bilateral

Question 16

what are the risk factors for AVN

Answer 16

irradiation,
trauma,
haematologic diseases (leukemia, lymphoma), sickle cell,
hypercoagulable staes,
dysbaric disorders (decompression sickness ‘the bends’ aka the bends)
alcoholism,
steroid use,

most cases idiopathic

Question 17

what is the usual presentation of AVN

Answer 17

insidious onset of groin pain,
exacerbated by stairs or impact,
examination is usually normal unless disease has advanced to collapse/ OA

Question 18

how can AVN be diagnosed

Answer 18

radiographs (normal in early disease)

MRI is most sensitive and specific

Question 19

what is the management for AVN dependent on

Answer 19

based on the stage of disease:
reversible
irreversible

Question 20

what is the management of avascular necrosis

Answer 20

if reversible:
bisphosphonates
core decompression +/- bone grafting 
curettage and bone grafting 
vascularised fibular bone graft 

rotational osteotomy

total hip replacement
(if irreverisble)

Question 21

what is idiopathic transient osteonecrosis of the hip (ITOH)

Answer 21

local hyperaemia and impaired venous return with marrow oedema and increase intraedullary pressure

Question 22

how does ITOH usually present

Answer 22

progressive groin pain over several weeks
difficulty weight bearing
usually unilateral

Question 23

who gets ITOH

Answer 23

males more than females

usually: middle ages females and pregnant women in third semester

Question 24

how do you diagnose ITOH

Answer 24

elevated ESR
radiographs: osteopenia of the head an neck, thinning of the cortices, preserved joint space
MRI (gold standard)
bone scan

Question 25

how is ITOH managed

Answer 25

self limiting condition that resolves in 6-9 months
analgesia so they can keep moving
protected weight bearing to avoid stress fracture

Question 26

what is trochanteric bursitis

Answer 26

repetitive trauma caused by iliotibial band tracking over trochanteric bursitis causing inflammation of the bursa

Question 27

who gets trochanteric bursitis

Answer 27

female patients, young runners and older patients (gluteal cuff syndrome- degenerative of)

Question 28

how does trochanteric bursitis

Answer 28

pain on LATERAL aspect of the hip

pain on palpation of the greater trochanter

Question 29

how do you diagnose trochanteric bursitis

Answer 29

clinical diagnosis
radiographs usually unremarkable
visible on MRI but not usually needed

Question 30

how is trochanteric bursitis managed

Answer 30

analgesia, NSAIDs, physio, steroid injection

no benefit from surgery

Question 31

what is osteoarthritis

Answer 31

degenerative disease of synovial joints that causes progressive loss of articular cartilage

inflammatory changes in the capsule lead to thickening and tightness

Question 32

who gets OA

Answer 32

females more than males, typically in older age, genetic element, pre existing hip disease

Question 33

what is the usual presentation of hip OA

Answer 33

groin pain, worse on activity, pain at night, start up pain (after resting for a while- lack of synovial fluid to lubricate the joint)
stiff on testing ROM

Question 34

what determines if a patient gets surgery for OA

Answer 34

level of symptoms 
impact of QOL
medical comorbidities 
social history 
do they want surgery

Question 35

what are the radiographic signs of OA

Answer 35

loss of joint space
osteophytes
subchondral sclerosis
subchondral cyst formation

Question 36

what is the management for OA

Answer 36

analgesia, weight loss walking aids, physio if weakness, ?steroids

THR

Question 37

what is the main indication for THR in OA

Answer 37

pain